title: Handoffs causing patient harm: a survey of medical and surgical house staff.
abstract: BACKGROUND
  Communication lapses at the time of patient handoffs are believed to be common, and yet the frequency with which patients are harmed as a result of problematic handoffs is unknown. Resident physicians were surveyed about their handoffpractices and the frequency with which they perceive problems with handoffs lead to patient harm.
  
  
  METHODS
  A survey was conducted in 2006 of all resident physicians in internal medicine and general surgery at Massachusetts General Hospital (MGH) concerning the quality and effects of handoffs during their most recent inpatient rotations. Surveys were sent to 238 eligible residents; 161 responses were obtained (response rate, 67.6%).
  
  
  RESULTS
  Fifty-nine percent of residents reported that one or more patients had been harmed during their most recent clinical rotation because of problematic handoffs, and 12% reported that this harm had been major. Overall quality of handoffs was reported to be fair or poor by 31% of residents. A minority of residents (26%) reported that handoffs usually or always took place in a quiet setting, and 37% reported that one or more interruptions during the receipt of handoffs occurred either most of the time or always.
  
  
  CONCLUSIONS
  Although handoffs have long been recognized as potentially hazardous, further scrutiny of handoffs has followed recent reports that handoffs are often marked by missing, incomplete, or inaccurate information and are associated with adverse events. In this study, reports of harm to patients from problematic handoffs were common among residents in internal medicine and general surgery. Many best-practice recommendations for handoffs are not observed, although the extent to which improvement of these practices could reduce patient harm is not known. MGH has recently launched a handoff-safety educational program, along with other interventions designed to improve the safety and effectiveness of handoffs, for its house staff and clinical leadership.
authors.affiliation: Institute for Health Policy, Department of Medicine, Massachusetts General Hospital, Boston, USA. bkitch@partners.org
authors.forename: Barrett T
authors.initials: BT
authors.lastname: Kitch
authors.forename: Jeffrey B
authors.initials: JB
authors.lastname: Cooper
authors.forename: Warren M
authors.initials: WM
authors.lastname: Zapol
authors.forename: Jessica E
authors.initials: JE
authors.lastname: Marder
authors.forename: Andrew
authors.initials: A
authors.lastname: Karson
authors.forename: Matt
authors.initials: M
authors.lastname: Hutter
authors.forename: Eric G
authors.initials: EG
authors.lastname: Campbell
mesh_terms: D003142:Communication; D003266:Continuity of Patient Care; D013502:General Surgery; D019538:Health Care Surveys; D008404:Massachusetts; D019300:Medical Errors; D008505:Medical Staff, Hospital; D010360:Patient Transfer; D011787:Quality of Health Care